How did you hear about the Rhode Island Special Needs Emergency Registry?
NOTE: By submitting this form to RIEMA/HEALTH, I agree to permit my information to be shared with local and state emergency responders. I understand that this is a voluntary program and while RIEMA/HEALTH will share this information in order to better assist me during an emergency, they cannot guarantee assistance in all cases.
If you are completing this form on someone's behalf, please indicate your name and relationship to that individual: